NCLEX- Neurology.questions and answers, Exams of Nursing

Download NCLEX- Neurology.questions and answers and more Exams Nursing in PDF only on Docsity! NCLEX- Neurology Jennifer Hickey [COMPANY NAME] Neurology NCLEX 1. The nurse is reinforcing home-care instructions to a client and family regarding care after cataract removal from the right eye. Which statement made by the client indicates an understanding of the instructions? Answer: "I should not sleep on my right side." 2. The nurse is assisting with caring for a client after a craniotomy. Which is the best position for the client to be placed? Answer: Semi-Fowler's position 3. The nurse is caring for a client following a supratentorial craniotomy, in which a large tumor was removed from the left side. In which position can the nurse safely place the client? Refer to Figures. Answer: A 4. The nurse is preparing to communicate with an older client who is hearing impaired. Which intervention should be implemented initially? Answer: Stand in front of the client. 5. Which intervention should be implemented for the older client with presbycusis who has a hearing loss? Answer: Use low-pitched tones. 6. The nurse is preparing to reinforce a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures should the nurse include in the plan? Select all that apply. Answer: To avoid activities that require bending over To place an eye shield on the surgical eye at bedtime To contact the surgeon if a decrease in visual acuity occurs To take acetaminophen (Tylenol) for minor eye discomfort 7. The nurse is assisting in developing a teaching plan for the client with glaucoma. Which instruction should the nurse suggest to include in the plan of care? Answer: Eye medications will need to be administered for the rest of your life. 8. The nurse is assigned to care for a client with a detached retina. Which finding should the nurse expect to be documented in the client's record? Answer: A sense of a curtain falling across the field of vision 9. The nurse is assigned to care for a client with a diagnosis of detached retina. Which finding would indicate that bleeding has occurred as a result of retinal detachment? Answer: Complaints of a burst of black spots or floaters 10. A client arrives in the emergency department after an automobile crash. The client's forehead hit the steering wheel, and a hyphema has been diagnosed. Which position should the nurse prepare to position the client? Answer: On bed rest in a semi-Fowler's position 11. A client sustains a contusion of the eyeball after a traumatic injury with a blunt object. The nurse should take which immediate action? Answer: Apply ice to the affected eye. 12. A client sustains a chemical eye injury from a splash of battery acid. The nurse should prepare the client for which immediate measure? Answer: Head turned to the side 34. The client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure (ICP) if the nurse observes the client doing which activity? Answer: Exhaling during repositioning 35. The client has clear fluid leaking from the nose after a basilar skull fracture. The nurse determines that this is cerebrospinal fluid (CSF) if the fluid meets which criteria? Answer: Separates into concentric rings and tests positive for glucose 36. The client is admitted to the hospital for observation with a probable minor head injury after an automobile crash. The nurse expects the cervical collar will remain in place until which time? Answer: The health care provider reviews the x-ray results. 37. The client was seen and treated in the emergency department (ED) for a concussion. Before discharge, the nurse explains the signs/symptoms of a worsening condition. The nurse determines that the family needs further teaching if they state they will return to the ED if the client experiences which sign/symptom? Answer: Minor headache 38. The nurse is caring for a client who has undergone craniotomy with a supratentorial incision. The nurse should plan to place the client in which position postoperatively? Answer: Head of bed elevated 30 to 45 degrees, head and neck midline 39. The client with a cervical spine injury has Crutchfield tongs applied in the emergency department. The nurse should perform which essential action when caring for this client? Answer: Comparing the amount of prescribed weights with the amount in use 40. The nurse has provided discharge instructions to a client with an application of a halo device. The nurse determines that the client needs further teaching if which statement is made? Answer: "I will drive only during the daytime." 41. The nurse is caring for the client who has suffered spinal cord injury. The nurse further monitors the client for signs of autonomic dysreflexia and suspects this complication if which sign/symptom is noted? Answer: Severe, throbbing headache 42. The client with spinal cord injury is prone to experiencing autonomic dysreflexia. The least appropriate measure to minimize the risk of autonomic dysreflexia is which action? Answer: Limiting bladder catheterization to once every 12 hours 43. The client with spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking vital signs, which immediate action should the nurse take? Answer: Raise the head of the bed and remove the noxious stimulus. 44. The nurse is assigned to care for an adult client who had a stroke and is aphasic. Which interventions should the nurse use for communicating with the client? Select all that apply. Answer: Face the client when talking. Speak slowly and maintain eye contact. Use gestures when talking to enhance words. Give the client directions using short phrases and simple terms. 45. The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has an ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which items into the client's room? Answer: Electrocardiographic monitoring electrodes and intubation tray 46. The nurse is attempting to communicate with a hearing-impaired client. Which strategy by the nurse would be least helpful when talking to this client? Answer: Smiling continuously during conversation 47. The nurse is reviewing the record of a client with mastoiditis. The nurse should expect to note which documented characteristic regarding the results of the otoscopic examination? Answer: Red, dull, thick, and immobile tympanic membrane 48. A client is diagnosed with a disorder involving the inner ear. The nurse caring for the client understands that which is the most common client complaint associated with a disorder involving the inner ear? Answer: Tinnitus 49. The nurse is reviewing the health care record of a client with a diagnosis of otosclerosis. The nurse should expect to note documentation of which early symptom of this disorder? Answer: Ringing in the ears 50. The nurse provides discharge instructions to the client who was hospitalized for an acute attack of Ménière's disease. Which statement made by the client indicates a need for further teaching? Answer: "It is not necessary to restrict salt in my diet." 51.The nurse is reinforcing instructions to a client regarding the use of a hearing aid. Which statement by the client indicates a need for further teaching? Answer: "I should turn the hearing aid off after removing it from my ear." 52. Tonometry is performed on the client with a suspected diagnosis of glaucoma. The nurse reviews the test and determines that the intraocular pressure is normal if which result is noted? Answer: 15 mm Hg 53. The nurse is assisting in developing a plan of care for the client scheduledfor cataract surgery. The nurse makes suggestions regarding the plan, knowing that which problem is specifically associated with this type of surgery? Answer: Sensory perceptual alteration 54. The nurse is reviewing the health record of a client diagnosed with a cataract. The initial sign/symptom that the nurse should expect to note in the early stages of cataract formation is which? Answer: Blurred vision 55. The nurse is assigned to care for a client following a cataract extraction. The nurse plans to place the client in which position? Answer: On the nonoperative side 56. During the early postoperative stage, the cataract extraction client complains of nausea and severe eye pain over the operative site. Which action should the nurse implement? Answer: Report the client's complaints. 57. The nurse is caring for a client with an intracranial aneurysm who was previously alert. Which finding should be an early indication that the level of consciousness (LOC) is deteriorating? Answer: Drowsiness 58. The nurse is planning to put aneurysm precautions in place for the client with a cerebral aneurysm. Which item should be included as part of the precautions? Answer: Maintaining the head of the bed at 15 degrees 59. The nurse is caring for a client who begins to experience seizure activity while in bed. Which action by the nurse would be contraindicated? Answer: Restrain the client's limbs. 60. The nurse is planning care for the client with hemiparesis of the right armand leg. Where should the nurse plan to place objects needed by the client? Answer: Within the client's reach, on the left side 61.The nurse is reinforcing instructions to the family of a stroke client who has homonymous hemianopsia about measures to help the client overcome the deficit. The nurse determines that the family understands the measures to use if they state that they will do which? Answer: Remind the client to turn the head to scan the lost visual field. 62. A client has experienced an episode of myasthenic crisis. The nurse collects data to determine whether the client has experienced which precipitating factor? Answer: Omitted doses of medication 63. A client with Parkinson's disease is embarrassed about the symptoms of the disorder and is bored and lonely. The nurse should plan which approach as therapeutic in assisting the client to cope with the disease? Answer: Encourage and praise perseverance in exercising and performing ADL. 64. The nurse has given suggestions to the client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client made which statement? Answer: "I will try to eat my food either very warm or very cold." 65. A client has an impairment of cranial nerve II. Specific to this impairment, the nurse plans to do which to ensure client safety? Answer: Provide a clear path for ambulation without obstacles. 66. The nurse reinforces home care instructions to a client after cataract removal and placement of an intraocular implant in the right eye. Which statement by the client indicates a need for further teaching? Answer: "I need to remove the eye dressing as soon as I get home and place a warm pack on my eye." Answer: Establishing a toileting schedule 89. The nurse has obtained a personal and family history from a client with a neurological disorder. Which finding in the client's history is least likely associated with a risk for neurological problems? Answer: Allergy to pollen 90. A client with right leg hemiplegia is experiencing difficulty with mobility. The nurse determines that the family needs reinforcement of teaching if the nurse observes which action by the family? Answer: Encouraging the client to stand unassisted on the leg 91. The nurse is preparing a client who is scheduled to have cerebral angiography performed. Which should the nurse check before the procedure? Answer: Allergy to iodine or shellfish 92. A client admitted to the hospital with a neurological problem indicates to the nurse that magnetic resonance imaging (MRI) may be done. Which finding noted in the client history indicates that the client may be ineligible for this diagnostic procedure? Answer: Prosthetic valve replacement 93. A client is somewhat nervous about having magnetic resonance imaging (MRI). Which statement by the nurse should provide reassurance to the client about the procedure? Answer: "Even though you are alone in the scanner, you will be in voice communication with the technologist during the procedure." 94.The nurse is trying to help the family of an unconscious client cope with the situation. Which intervention should the nurse plan to incorporate into the care routine for the client? Answer: Explaining equipment and procedures on an ongoing basis 95. The nurse is suctioning an unconscious client who has a tracheostomy. The nurse should avoid which action during this procedure? Answer: Making sure not to suction for longer than 30 seconds 96. The nurse has applied a hypothermia blanket to a client with a fever. The nurse should inspect the skin frequently to detect which complication of hypothermia blanket use? Answer: Skin breakdown 97. The nurse is caring for an unconscious client who is experiencing persistent hyperthermia with no signs and symptoms of infection. The nurse understands that there may be damage to the client's thermoregulatory center which is located in which part of the brain? Answer: Hypothalamus 98. A client seeking treatment for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client makes which statement? Answer: "I can resume a full activity level immediately." 99. The family of an unconscious client with increased intracranial pressure istalking at the client's bedside. They are discussing the gravity of the client's condition and wondering if the client will ever recover. How should the nurse interpret the client's situation? Answer: It is possible the client can hear the family. 100. The nurse is providing care to a client with increased intracranial pressure (ICP). Which approaches would be beneficial in controlling the client's ICP from an environmental viewpoint? Select all that apply. Answer: Reducing environmental noise Maintaining a calm atmosphere Allowing the client uninterrupted time for sleep 101. The nurse is preparing to give the postcraniotomy client medication for incisional pain. The family asks the nurse why the client is receiving codeine sulfate and not "something stronger." The nurse should formulate a response based on which understanding of codeine? Answer: Codeine does not alter respirations or mask neurological signs as do other opioids. 102. The nurse reinforces home care instructions to the postcraniotomy client. Which statement by the client indicates the need for further teaching? Answer: "I will not hear sounds clearly unless they are loud." 103. The nurse notes documentation that a postcraniotomy client is having difficulty with body image. The nurse determines that the client is still working on the postoperative outcome criteria when the client indicates which altered personal appearance? Answer: Indicates that facial puffiness will be a permanent problem 104. A client with spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. Which is the best response by the nurse? Answer: Acknowledge the client's anger and continue to encourage participation in care. 105. A client with a spinal cord injury expresses little interest in food and is very particular about the choice of meals that are actually eaten. How should the nurse interpret this? Answer: Meal choices represent an area of client control and should be encouraged as much as is nutritionally reasonable. 106. A client who is paraplegic after spinal cord injury has been taught muscle-strengthening exercises for the upper body. The nurse determines that the client will derive the least muscle-strengthening benefit from which activity? Answer: Doing active range of motion to finger joints 107. A client with diplopia has been taught to use an eye patch to promote better vision and prevent injury. The nurse determines that the client understands how to use the patch if the client states that he or she will do which? Answer: Wear the patch continuously, alternating eyes each day. 108. The nurse is planning care for a client in spinal shock. Which action would be least helpful in minimizing the effects of vasodilation below the level of the injury? Answer: Moving the client quickly as one unit 109. The nursing instructor asks a nursing student about the points to document if the client has had a seizure. The instructor determines that the student needs to research seizures and related documentation points if the student states which assessment is important? Answer: Client's diet in the 2 hours preceding seizure activity 110. The nurse is planning to institute seizure precautions for a client who is being admitted from the emergency department. Which measure should the nurse avoid in planning for the client's safety? Answer: Putting a padded tongue blade at the head of the bed 111. The nurse has given medication instructions to the client receiving phenytoin (Dilantin). The nurse determines that the client understands the instructions if the client makes which comment? Answer: "Good oral hygiene is needed, including brushing and flossing." 112. A client with a stroke (brain attack) has residual dysphagia. When a diet prescription is initiated, the should nurse avoid which action? Answer: Giving the client thin liquids 113. The nurse is trying to communicate with a stroke (brain attack) client with aphasia. Which action by the nurse would be least helpful to the client? Answer: Completing the sentences that the client cannot finish 114. A client receives a dose of edrophonium (Enlon). The client shows improvement in muscle strength for a period of time following the injection. The nurse should interpret this finding as indicative of which disease process? Answer: Myasthenia gravis 115. A client with myasthenia gravis is having difficulty speaking. The client's speech is dysarthric and has a nasal tone. The nurse should use which communication strategies when working with this client? Select all that apply. Answer: Listening attentively Asking yes and no questions when able Using a communication board when necessary Repeating what the client said to verify the message 116. The nurse is teaching the client with myasthenia gravis about prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by which activity? Answer: Taking medications on time to maintain therapeutic blood levels 117. The nurse has instructed the client with myasthenia gravis about ways to manage his or her own health at home. The nurse determines that the client needs further teaching if the client makes which statements? Answer: "Going to the beach will be a nice, relaxing form of activity." 118. A client with Parkinson's disease is experiencing a parkinsonian crisis. The nurse should immediately place the client where? Answer: In a quiet, dim room with respiratory and cardiac support available 119. The nurse has given instructions to the client with Parkinson's disease about maintaining mobility. The nurse determines that the client understands the directions if the client states that he or she will perform which activity? 140. The nurse collects data from a client with a diagnosis of macular degeneration of the eye. The nurse should expect the client to report which symptom? Answer: Blurred central vision 141. The nurse is reinforcing instructions to a client with a diagnosis of hordeolum regarding the treatment plan. Which instruction should the nurse include in the teaching plan for the client? Answer: Apply a warm compress for 15 minutes four times daily. 142. The nurse in the ambulatory care unit is caring for a client following cataract extraction. The client suddenly complains of nausea and severe eye pain in the surgical eye. The nurse should take which action? Answer: Notify the registered nurse. 143. A client arrives at the emergency department after experiencing a traumatic blow to the eye and a hyphema is diagnosed. In which position should the nurse place the client? Answer: In semi-Fowler's position 144. A client who was hit in the eye with a baseball bat sustains a contusion of the eyeball. The emergency department nurse implements which immediate action? Answer: Applies ice to the affected eye 145. A client arrives in the emergency department with an eye injury caused by metal fragments that hit the eye while the client was drilling into metal. The nurse checks the eye and notes small pieces of metal floating on the eyeball. Which action should the nurse plan to assist with first? Answer: Irrigate the eye with sterile saline. 146. A client arrives in the emergency department with a chemical eye injury. The nurse immediately performs which action? Answer: Irrigates the eye with copious amounts of sterile normal saline 147. The nurse is reviewing the plan of care developed by a nursing student for a client scheduled for keratoplasty. The nurse discusses the plan with the student if which incorrect intervention is listed in the plan? Answer: Administering medications that will dilate the pupil 148. The nurse is providing discharge instructions to a client following a keratoplasty. Which statement by the client indicates the need for further teaching? Answer: "Sutures are removed in 2 weeks." 149. The nurse is caring for a client following enucleation. On data collection, the nurse notes staining and bleeding on the dressing. The nurse should take which action? Answer: Notify the registered nurse. 150. The nurse is monitoring a client with a head injury and notes that the client is assuming the posture shown in the figure. What is the client exhibiting that would require the nurse to notify the registered nurse immediately? Refer to the figure. Answer: Decorticate posturing 151. The nurse is inserting soft contact lenses into the eyes of a client. Which direction does the nurse tell the client to look? Answer: Straight ahead 152. The nurse is providing client and family instructions for a client who has been recently diagnosed with glaucoma. Which statement indicates that the client's family member needs further teaching regarding the eye drop application of pilocarpine hydrochloride (Isopto Carpine)? Select all that apply. Answer: "I should apply the eye drops directly over my family member's pupil." "I have to contact the prescriber if my family member develops a small pupil." "I need to wipe off the tip of the eye drop bottle with a tissue between administrations." 153. The nurse is assisting in caring for a client who sustained a traumatic head injury following a motor vehicle crash. The nurse documents that the client is exhibiting decerebrate posturing. The nurse bases this documentation on which observation? Answer: Extension of the extremities and pronation of the arms 154. The nurse is caring for a client diagnosed with Bell's palsy 1 week ago. Which data would indicate a potential complication associated with Bell's palsy? Answer: Excessive tearing 155. The nurse is collecting data on a client suspected of having Alzheimer's disease. The priority data should focus on which characteristic of this disease? Answer: Recent memory loss 156. The nurse is monitoring a client with a C5 spinal cord injury for spinal shock. Which findings would be associated with spinal shock in this client? Select all that apply. Answer: Bowel sounds are absent. The client's abdomen is distended. Respiratory excursion is diminished. Accessory muscles of respiration are areflexic. 157. The nurse is ambulating a client with a known seizure disorder. The client says, "I'm seeing those flashing lights again," then loses consciousness and develops a clonic-tonic seizure. Which would be the nurse's initial action? Answer: Assist the client to the floor. 158. The nurse is collecting data on a client with myasthenia gravis. The nurse determines that the client may be developing myasthenic crisis if the client makes which statement? Answer: "I can't swallow very well today." 159. The nurse is providing client teaching regarding glaucoma. Which instructions are important to include in the teaching plan? Select all that apply. Answer: Follow a low-sodium, minimal-caffeine diet with plenty of fiber. Be sure to report halos of light or increased eye pain to your health care provider. 160. A client arrives at the emergency department following a blow to the eye from a softball. Which intervention should be implemented by the nurse initially? Answer: Apply ice to the affected eye. 161. While at home, the nurse receives a telephone call from a neighbor, who reports that while accidentally breaking a mirror, a piece of glass flew into her eye. Which is the appropriate initial nursing action after observing that the large glass shard is protruding from the neighbor's eye? Answer: Secure a paper cup over the affected eye. 162. A client arrives at the emergency department following an eye injury in which an acid used to clean the brick on the fireplace splashed into the eye. Which question should the nurse ask initially? Answer: "Did you flush the eye following the injury?" 163. The nurse is caring for a client following enucleation. Which postsurgical observation requires immediate attention by the nurse? Answer: Bright red drainage on the dressing 164. Which instruction is appropriate for the nurse to provide to a client who reports via telephone that he is certain an insect has flown into his ear because he can hear it "buzzing"? Answer: Use a flashlight to coax the insect out of the ear. 165. Which statement by the nurse indicates an understanding of the diagnosis of presbycusis? Answer: "It is a sensorineural type of hearing loss that occurs with aging." 166. The nurse determines that the client diagnosed with Ménière's disease understands the reinforced dietary instructions when the client states that which food will be avoided in the diet? Answer: Hot dogs 167. The nurse is assisting in developing a plan of care for a client following the surgical removal of an acoustic neuroma. Which assessment will be included in the plan of care for this specific intervention? Answer: Assessment of cranial nerve VII (facial) 168. A client is being discharged from the ambulatory care unit following cataract removal. Which instruction from the discharge teaching plan should the nurse reinforce? Answer: Take acetaminophen (Tylenol) if any discomfort occurs. 169. The nurse is reinforcing instructions to a client following a cataract extraction on the right eye. Which statement by the client indicates a need for further teaching? Answer: "I need to wear an eye shield all the time." 170. When the nurse documents the results of a Snellen vision test as 20/80 vision, the client asks the nurse to describe what these numbers mean. Which statement is the appropriate response? Answer: "You can read at a distance of 20 feet what a client with normal vision can read at 80 feet." 193. The nurse is preparing for the admission of a client with a suspected diagnosis of herpes simplex encephalitis. Which diagnostic test should be prescribed to confirm this diagnosis? Answer: Brain biopsy 194. The nurse is caring for a client with a diagnosis of multiple sclerosis who has been prescribed oxybutynin (Ditropan). The nurse evaluates the effectiveness of the medication by asking the client which question? Answer: "Are you getting up at night to urinate?" 195. The nurse is preparing for the admission of a client with a suspected diagnosis of Guillain-Barré syndrome. Which sign/symptom is considered a primary symptom of this syndrome? Answer: Development of muscle weakness 196. A thymectomy via a median sternotomy approach is performed on a client with a diagnosis of myasthenia gravis. The nurse has assisted in developing a plan of care for the client and includes which nursing action in the plan? Answer: Monitor the chest tube drainage. 197. The nurse is caring for a client with a diagnosis of right (nondominant) hemispheric brain attack (stroke). The nurse notes that the client is alert and oriented to time and place. Based on these findings, the nurse makes which determination? Answer: The client may have perceptual and spatial disabilities. 198. The nurse is preparing to care for a client with a diagnosis of brain attack (stroke). The nurse notes in the client's record that the client has anosognosia. The nurse plans care, knowing which is a characteristic of anosognosia? Answer: The client neglects the affected side. 199. The nurse is preparing a plan of care for a client with a brain attack (stroke) who has global aphasia. The nurse incorporates communication strategies in the plan of care, knowing that the client's speech should fit which characterization? Answer: Associated with poor comprehension 200. The nurse is caring for a client with a diagnosis of brain attack (stroke) with anosognosia. To meet the needs of the client with this deficit, which action does the nurse plan? Answer: Increase the client's awareness of the affected side. 201. The nurse is caring for a client who sustained a spinal cord injury. While administering morning care, the client developed signs and symptoms of autonomic dysreflexia. Which is the initial nursing action? Answer: Elevate the head of the bed. 202. Prescriptive eyeglasses are prescribed for a client with bilateral aphakia. When reinforcing teaching instructions regarding the eyeglasses, the nurse determines the need for further teaching when the client makes which statement? Answer: "My peripheral vision will not be distorted." 203. The nurse has reinforced instructions to a client who is scheduled for a cataract extraction. Which statement by the client indicates a need for further teaching? Answer: "No eating or drinking for at least 18 hours before the surgery." 204. The nurse in the recovery room area is preparing to care for a client following cataract extraction of the right eye. Which position does the nurse prepare to place the client? Answer: On the left side with the head of the bed elevated 205. A client who sustained an eye injury arrives at the emergency department. Which is the initial nursing action? Answer: Obtain a history regarding the cause of the injury. 206. A client arrives at the emergency department for treatment of an injury to the eye after being hit by a baseball bat. On data collection, the nurse notes that the eye is bleeding. Which nursing action is appropriate? Answer: Cover the eye with cold, sterile saline gauze. 207. A client arrives in the emergency department following an eye injury from a chemical solution. Which is the initial nursing action? Answer: Test the eye pH with litmus paper. 208. The nurse is reviewing the preoperative prescriptions of a client scheduled for a keratoplasty. Which prescriptions noted in the client's chart should the nurse question? Answer: Administer medication to dilate the affected pupil. 209. The nurse has reinforced instructions to a client following a right keratoplasty. Which statement by the client indicates a need for further teaching? Answer: "In 1 week, I'll return to have the sutures removed." 210. The nurse caring for a client in the postoperative period following an enucleation notes bloody staining on the surgical eye dressing. Which is the appropriate nursing action? Answer: Contact the health care provider. 211. A client reporting recent right eye discomfort is diagnosed with chalazion of the right eye. The nurse reinforces instructions to the client regarding care to the eye. Which statement by the client indicates an understanding of the measures? Answer: "I should apply warm packs to my eye." 212. The nurse is reinforcing home care instructions to a client who has a hordeolum (sty) of the right eye. Which statement by the client indicates an understanding of the instructions? Answer: "I should apply antibiotic ointment as prescribed." 213. The nurse is assisting the health care provider in performing a caloric test on a client. Following instillation of cool water into the ear, the nurse observes the presence of nystagmus. The nurse should document the findings of this test as indicative of which result? Answer: Normal 214. The nurse is assisting the health care provider in performing a caloric test on a client. Following instillation of warm water into the ear, the client complains of vertigo. The nurse documents the findings of this test as indicative of which result? Answer: Normal 215. The nurse is assisting a health care provider in performing a caloric test on a client. Following instillation of warm water into the ear, the nurse notes that nystagmus does not occur. The nurse should document the findings of this test as indicative of which result? Answer: Positive 216. A caloric test is prescribed for a client suspected of having a disease of the labyrinth. The nurse obtains which essential item in preparation for this test? Answer: An otoscope 217. A nursing instructor asks a student about cochlear implants. The student understands that which clients are candidates for such a procedure? Select all that apply. Answer: A client who has a profound hearing loss in both ears A client who has received no benefit from conventional hearing aids 218. A female client with myasthenia gravis comes to the health care provider's office for a scheduled office visit. The client is very concerned and tells the nurse that her husband seems to be avoiding her because she is very unattractive. Which is the appropriate nursing response? Answer: "Have you thought about sharing your feelings with your husband?" 219. The nurse assigned to care for a hearing-impaired client should use which approach to communication in order to enhance communication and preserve the client's self- esteem? Select all that apply. Answer: Speaking slowly and clearly Standing directly in front of the client while speaking Turning down the volume on the radio or TV when talking 220. The nurse is reinforcing discharge instructions to a client going home after same-day eye surgery. During the postoperative period, the nurse stresses that the client may safely perform which activity? Answer: Watch television. 221. The nurse is reinforcing discharge instructions to a client who has had ocular surgery of the left eye. Which statement by the client indicates a need for further teaching? Answer: "I need to call the doctor if I develop any fever." 222. A client who had previously undergone cataract surgery tells the nurse that she has begun seeing flashing lights and floaters in the eye. Based on the client's history, the nurse interprets that the client is at risk for which? Answer: Detached retina 223. A client diagnosed with primary open-angle glaucoma has been prescribed pilocarpine ophthalmic drops. When the client asks the nurse how this medication lowers intraocular pressure, which information does the nurse tell the client? Answer: The medication increases the outflow of aqueous humor. 224. The nurse interprets that a client diagnosed with glaucoma needs information about the expected effects of this condition when the client makes which statement? Answer: "Taking my daily walk right around dusk each evening has proven to be so enjoyable." Maintain the client in a flat position. Monitor the client's ability to move the extremities. Inspect the puncture site for swelling, redness, and drainage. 243. A client with Parkinson's disease "freezes" while ambulating, increasing the risk for falls. Which suggestion should the nurse include in the client's plan of care to alleviate this problem? Answer: Consciously think about walking over imaginary lines on the floor. 244. The nurse is assisting in checking for Tinel's sign in a client suspected of having carpal tunnel syndrome (CTS). Which technique should the nurse expect to be used to elicit this sign? Answer: Percuss the medial nerve at the wrist as it enters the carpal tunnel, and monitor for tingling sensations. 245. The nurse is monitoring a client with a spinal cord injury who is experiencing spinal shock. Which assessment will provide the nurse with the best information about recovery from the spinal shock? Answer: Reflexes 246. The nurse is caring for a client with a cerebral aneurysm who is on aneurysm precautions and is monitoring the client for signs of aneurysm rupture. The nurse understands that an early sign of rupture is which? Answer: A decline in the level of consciousness 247. The nurse is caring for a client with a head injury and is monitoring the client for signs of increased intracranial pressure (ICP). Which sign if noted in the client should the nurse report immediately? Answer: The client vomits. 248. The nurse is caring for a client with a spinal cord injury. High-top sneakers on the client's feet will prevent the occurrence of which? Answer: Foot drop 249. A halo vest is applied to a client following a cervical spine fracture. The nurse reinforces instructions to the client regarding safety measures related to the vest. Which statement by the client indicates a need for further teaching? Answer: "I will bend at the waist, keeping the halo vest straight to pick up items." 250. The nurse is preparing a plan of care to monitor for complications in a client who will be returning from the operating room following transsphenoidal resection of a pituitary adenoma. Which intervention does the nurse document in the plan as the priority nursing intervention for this client? Answer: Monitor urine output. 251. The nurse is reinforcing discharge instructions to a client who has undergone transsphenoidal surgery for a pituitary adenoma. Which statement by the client indicates the client understands the discharge instructions? Answer: "I need to call the doctor if I develop frequent swallowing or postnasal drip." 252. The nurse is collecting admission data on a client with Parkinson's disease. The nurse asks the client to stand with the feet together and the arms at the side and then to close the eyes. The nurse notes that the client begins to fall when the eyes are closed. Based on this finding, the nurse documents which in the client's record? Answer: Positive Romberg's test 253. A nursing student is collecting data on a client recently diagnosed with meningitis. The student expects to note which signs and symptoms? Select all that apply. Answer: Tachycardia Photophobia Red, macular rash Positive Kernig's sign 254. The nurse is reinforcing discharge instructions to a client following right eye cataract surgery about ways to avoid strain on the operative eye. The nurse determines that the client needs further teaching if the client makes which statement? Answer: "I can lie on my right side." 255. The nurse is caring for a client with acute otitis media. The nurse plans care knowing which treatment for this problem is likely to be included? Answer: Myringotomy 256. The nurse is assisting in preparing a teaching plan for a client with Ménière's disease. The nurse places highest priority on teaching the client information related to which information? Answer: Safety 257. The nurse is reviewing the results of an eye examination on a client. Which tests can detect glaucoma? Select all that apply. Answer: Tonometry Visual field check 258. A client is suspected of having a diagnosis of Guillain-Barré syndrome (GBS). Which findings would support a diagnosis of Guillain-Barré syndrome? Select all that apply. Answer: Visual and hearing disturbances Ascending symmetrical muscle weakness 259. The nurse is preparing a plan of care for a client being admitted to the hospital with a diagnosis of retinal detachment. Which measure should the nurse include in the plan of care? Answer: Place an eye patch over the affected eye. 260. The nurse is reinforcing home care instructions to a client following a fenestration procedure for the treatment of otosclerosis. Which instruction should the nurse give the client? Answer: Increase fluids and take a stool softener daily. 261. The nurse is reviewing the health care record of a client suspected of having mastoiditis. Which finding does the nurse expect to note if this disorder is present? Answer: Swelling behind the ear 262. A nursing student is caring for a client in the health care clinic who has been diagnosed with glaucoma. The nursing instructor asks the student to describe the types of medication that will likely be prescribed for the client to treat the eye disorder. Which drug classification will facilitate the outflow of aqueous humor? Answer: Cholinergic miotic agents 263. A nursing student is preparing to assist with an ear irrigation on an assigned client who has a buildup of cerumen in the left ear. The nursing instructor asks the student about the procedure for the irrigation. The student nurse should perform the procedure in which correct order? Arrange the actions in the order that they should be used. All options must be used. Answer: Warm the prescribed solution to body temperature (95° F to 105° F). Have the client sit up holding an emesis basin under the ear to be irrigated with a drape under the basin. Straighten the external canal of an adult by pulling the auricle up and back. Select an irrigating syringe or bulb syringe with a tip that is smaller than the canal. Direct the solution toward the top of the canal in a steady stream, not toward the eardrum. 264. A clinic nurse is reinforcing home care instructions to a client with a diagnosis of glaucoma. Which statement by the client indicates an understanding of the treatment plan for glaucoma? Answer: "I need to take my eye drops for the rest of my life." 265. The nurse is observing an unlicensed assistive personnel (UAP) talk to a client who is hearing impaired. The nurse should intervene if which action is performed by the UAP during communication with the client? Answer: The UAP speaks directly into the impaired ear. 266. A clinic nurse is reinforcing instructions to a client regarding the use of a hearing aid. Which statement by the client indicates a need for further teaching? Answer: "I should turn the hearing aid off after removing it from my ear." 267. The nurse is collecting data on a client diagnosed with Parkinson's disease. Which finding indicates a serious complication of this disorder? Answer: Congested cough and coarse rhonchi heard during auscultation 268. The nurse notices that a client with trigeminal neuralgia has been withdrawn, is having frequent episodes of crying, and is sleeping excessively. Which method is the best way for the nurse to explore issues with the client regarding these behaviors? Answer: Have the client express the feelings in writing. 269. A client with suspected Guillain-Barré syndrome has a lumbar puncture performed. The cerebrospinal fluid (CSF) protein is 750 mg/dL. The nurse analyzes these results as which? Answer: Higher than normal, supporting the diagnosis of GuillainBarré Computed tomography 290. When the nurse taps at the level of the client's facial nerve, the following response is noted. How should the nurse document this finding on the client record? Refer to figure. Answer: Positive Chvostek's sign 291. The nurse is collecting neurological data on an unconscious client. On application of a central noxious stimulus, the nurse observes this response. How should the nurse document this response on the client's record? Refer to figure. Answer: Client demonstrated decerebrate posturing. 292. The nurse suspects neurogenic shock in a client with complete transection of the spinal cord at the T3 (thoracic 3) level if which clinical symptoms are observed? Answer: Hypotension and bradycardia 293. The nurse is told in report that a client has a positive Chvostek's sign. Which other data should the nurse expect to find on data collection? Select all that apply. Answer: Tetany Diarrhea Possible seizure activity Positive Trousseau's sign 294. A client with glaucoma and an acute exacerbation of chronic obstructive pulmonary disease (COPD) has a new prescription to receive carteolol HCl (Ocupress) eye drops. Which action by the nurse is most appropriate? Answer: Withhold the dose and notify the registered nurse. 295. The nurse determines that motor function of which cranial nerve is intact if the client can perform this action? Refer to figure. Answer: Facial 296. A client complains of pain in the lower back and pain and spasms in the hamstrings when the nurse attempts to extend the client's leg. How should the nurse record this finding on the client's medical record? Refer to figure. Answer: Positive Kernig's sign 297. A client with a stroke (brain attack) is experiencing residual dysphagia. The nurse should remove which food items that arrived on the client's meal tray from the dietary department? Answer: Peas 298. The nurse is reinforcing instructions to a client regarding the use of ice packs to treat an eye injury. The nurse instructs the client to do which action? Answer: Wrap a plastic bag filled with ice with a pillowcase and place it on the eye. 299. The nurse is caring for a client following craniotomy who has a supratentorial incision. The nurse reviews the client's plan of care, expecting to note that the client should be maintained in which position? Answer: Semi-Fowler's position 300. A client is about to undergo a lumbar puncture (LP). The nurse tells the client that which position will be used during the procedure? Answer: Side-lying with the legs pulled up and the head bent down onto the chest 301. The nurse is speaking with a client with a hearing impairment. The nurse refrains from doing which least likely helpful action when communicating with this client? Answer: Using many exaggerated hand gestures while talking 302. The nurse is gathering data from a client with a history of untreated cataracts. The nurse asks the client about the presence of which sign of a cataract? Answer: Difficulty with driving at night and blurred vision 303. The nurse is assisting a client who has just been given a hearing aid to wear for the first time. When reinforcing client teaching, the nurse should include which instruction? Answer: "The hearing aid should not be worn if an ear infection is present." 304. The nurse is attempting to inspect the lacrimal apparatus of a client's eye. Because of its anatomical location the nurse should do which action? Answer: Retract the upper eyelid and ask the client to look down. 305. A client has been newly diagnosed with glaucoma. As part of the discharge instructions, the nurse should plan to reinforce which information? Answer: The need for lifelong medication therapy 306. A client is diagnosed with hyphema after experiencing a traumatic blow to the eye. The nurse explains to the client that which activity limitation needs to be implemented following this type of injury? Answer: Bed rest with the head in semi-Fowler's position 307. A client arrives in the emergency department with an eye injury resulting from metal fragments that hit the eye while the client was drilling into metal. The nurse checks the eye and notes small pieces of metal floating on the eyeball. Which action should the nurse take first? Answer: Irrigate the eye with sterile saline. 308. A client has been diagnosed with glaucoma. The nurse who is teaching the client principles of self-care should encourage the client to limit or refrain from which usual activity on a repeated basis? Answer: Picking objects up off the floor 309. The nurse is explaining how sound is conducted from the middle ear to the inner ear in teaching a client who is experiencing hearing loss. The nurse plans to use a diagram that illustrates how which bones connects to the cochlea at the oval window? Answer: Stapes 310. The nurse is developing a poster to use in teaching clients about the prevention of hearing loss. The nurse should diagram which structure as part of the inner ear? Answer: Cochlea 311. An adult client has increased fluid in the middle ear, which is causing vertigo. The nurse checks this client for which associated signs and symptoms of this condition? Answer: Nausea and vomiting 312. The nurse has been assigned to a client with a hearing impairment. To enhance nurse- client communication, the nurse should plan to communicate with the client by speaking in which manner? Answer: In a normal tone while facing the client 313. The nurse is reviewing the medication list for an assigned client. Which medication is the only one on the client's prescription sheet that does not have an ototoxic effect? Answer: Acetaminophen (Tylenol) 314. A client has just undergone lumbar puncture (LP). The nurse assists the client into which optimal position? Answer: Prone, with a pillow under the abdomen 315. A client with Bell's palsy exhibits facial asymmetry and cannot close the eye completely on one side. The client is also drooling and has loss of tearing in one eye. The nurse documents that the client displays symptoms of involvement of which cranial nerves (CNs)? Answer: CN VII 316. The nurse is caring for the client with a head injury secondary to a motor vehicle crash. The nurse observes the client's status regularly, monitoring closely for which change in vital signs that could indicate increased intracranial pressure? Answer: Decreasing pulse, decreasing respirations, increasing BP 317. A client who sustained a closed head injury has a new onset of copious urinary output. Urine output for the previous 8-hour shift was 3300 mL, and 2800 mL for the shift before that. The findings have been reported to the health care provider, and the nurse anticipates a prescription for which medication? Answer: Desmopressin (DDAVP) 318. A client who suffered a cervical spine injury had Crutchfield tongs applied in the emergency department. The nurse should avoid which action in the care of the client? Answer: Removing the weights when repositioning the client 319. The nurse is reinforcing instructions to the client who has just been fitted for a halo vest. Which statement by the client indicates the need for further teaching? Answer: "I will avoid driving at night because the vest limits the ability to turn the head." 320. A client with spinal cord injury has experienced more than one episode of autonomic dysreflexia. The nurse should avoid which action that could trigger an episode of this complication? Answer: Allowing the client's bladder to become distended 321. The nurse is assisting in admitting a client who experienced seizure activity in the emergency department. The nurse avoids which action when managing this client's environment? Answer: Keeping the bed position raised to the nurse's waist level